Syncope and The Older Patient

1
Syncope and The Older Patient

• Debra L. Bynum, MD
• Division of Geriatric Medicine

2
Pretest

• 1. The ECG has the greatest value in its (NPV or
  PPV) in the diagnosis of a cardiac etiology for
  syncope
• 2. History 75 year old man reports presyncopal
  symptoms that occur while he is driving backwards
  out of his driveway in the morning. This
  suggests
• 3. History an 80 year old man reports an episode
  of syncope that occurred after doing arm
  exercises for a rotator cuff injury. This
  suggest
• 4. The only independent predictor of a cardiac
  etiology of syncope is a past history of
• 5. ____ is a neurodegenerative disease
  characterized by profound autonomic insufficiency
  and parkinsonian features on exam
• 6. An 82 year old man presents with postural
  hypotension, an idiopathic peripheral neuropathy,
  significant proteinuria and your attending orders
  a rectal biopsy to look for____
• 7. Name 3 causes of situational syncope
• 8. Older patients are more likely to have
  positive a. tilt table tests b. carotid sinus
  massage c. orthostatic hypotension d. all of the
  above

3
Pretest bonus question

• Sudden cardiac death in young men (originally
  described in young asian men) associated with
  this sign on EKG is known as what syndrome?

4
Syncope Definition

• Sudden and temporary loss of consciousness with
  inability to maintain postural tone, followed by
  spontaneous recovery

5
Causes of Syncope

• Neurally Mediated (up to 58 in some series)
• Orthostatic/postural
• Cardiac arrhythmia (20-25)
• Structural cardiac or pulmonary causes
• Cerebrovascular or psychiatric (1)
• Unknown (18-30)

6
Syncope in the Elderly

• Usually multifactorial
• Often confounded by findings (orthostasis and
  carotid hypersensitivity common and may be found
  and yet not be the cause)
• Prevalence up to 25 in nursing home population
  over age 70
• Higher pretest probability of cardiac disease or
  arrhythmia

7
Importance of History and PE

• Up to 70 of patients in prospective studies had
  probable cause identified based upon history,
  physical exam and ecg

8
The History

• History of Heart Disease
• The ONLY independent predictor of cardiac cause
  (sens 95, spec 45)
• Absence of heart disease up to 97 specific to
  rule out cardiac etiology (good NPV)

9
The History

• Position
• Supine cardiac until proven otherwise
• Upon sitting/standing orthostasis
• Prolonged standing venous pooling/orthostasis/vas
  ovagal
• Presyncopal symptoms
• Presence suggests vasovagal, but does not rule
  out arrhythmia
• Lack of suggests arrythmia (up to 65 with sudden
  syncope)
• Dyspnea (Pulmonary embolus)
• Focal neurologic symptoms (TIA, seizure)
• Seizure like activity (including loss of bowel
  and bladder control, tongue bite, postictal state)

10
The history

• Recovery period
• Instant arrythmia
• Feeling hot and nauseated vasovagal
• Confusion/lethargy postictal
• Situational syncope (vasovagal)
• Cough
• Swallow (cold liquid)
• Micturition (urination)
• Defecation
• Exertional
• Ventricular tachyarrhythmia
• Aortic stenosis or HOCM
• Pulmonary Hypertension

11
The history

• Prior faint 1-4 years prior suggest vasovagal
• Age
• Medications
• Tricyclic antidepressants
• Nitrates
• Alpha adrenergic antagonists
• Diuretics
• Injury (facial suggests arrhythmia)
• Postprandial (vagally mediated)

12
Specific Causes and Treatment Options for Syncope

• Postural Hypotension
• Drop in systolic blood pressure of over 20
• Medications
• Autonomic Insufficiency
• No reflex tachycardia
• Shy-Drager (multiple systems atrophy)
• Primary autonomic failure
• Parkinsons Disease
• Diabetes
• Aging
• Amyloid
• Volume Loss
• Dehydration
• Blood loss

13
Autonomic Insufficiency and Orthostatic
Hypotension

• Treatment Options
• Review of medications
• Avoid volume depletion
• Arising slowly
• Tensing crossed legs while standing
• Dorsiflex feet or handgrip prior to standing
• Thigh high Jobst stockings (decreases venous
  pooling)
• Avoid prolonged standing (venous pooling)
• Increased salt diet
• Smaller meals to avoid postprandial drop in BP
• Fludrocortisone
• Midodrine (alpha 1 adrenergic agonist)
• Phenylephrine (not usually used in older
  patients)
• Fluoxetine

14
Mechanical Cardiac Causes

• Obstruction to LV outflow
• Aortic Stenosis
• HOCM
• Left atrial myxoma
• Mitral Stenosis
• Obstruction to pulmonic flow
• Pulmonic stenosis
• Pulmonary HTN
• PE (can also have vasovagal type syncope
  associated with smaller PEs)
• Right atrial myxoma

15
Other Mechanical Cardiac Causes

• Large MI with LV dysfunction
• CHF
• Tamponade
• Aortic dissection

16
Cardiac Arrhythmias

• Bradycardia
• Sick sinus syndrome
• 2nd or 3rd degree AV block
• Pacemaker malfunction
• Tachycardia
• Ventricular tachycardia
• Ventricular fibrillation
• SVT
• If you see atrial fibrillation, think sick sinus
  syndrome as potential cause of syncope

17
Brugada Syndrome

• Triad
• RBBB pattern in right precordial leads
• Transient/persistent ST elevation in v1-v3
• Sudden cardiac death
• Structurally normal heart
• Association with young and healthy men from
  southeast asia who present with sudden cardiac
  death
• Brugada sign may be asymptomatic
• High risk of sudden cardiac death in those who
  have syncope or family history of sudden death
  (Indication for AICD based upon observational
  data)

18
Brugada Sign
19
Implantable Cardioverter-Defribrillator Guidelines

• AICD indicated for patients with spontaneous
  Vtach with underlying heart disease or in
  patients with normal heart when vtach not
  amenable to other treatments

20
AICD guidelines

• Ischemic Cardiomyopathy
• LVEF
• At least 1 month after MI and 3 months after
  revascularization
• MADIT-II trial
• Multicenter Automatic Defibrillator Implantation
  Trial
• 5.6 ARR in mortality over 4 years
• Results support prophylactic AICD, but not
  considered cost wise
• Based upon subset analysis, Current
  recommendation in those with QRS 120 ms
• Unclear result those with ICDs had 5 absolute
  increased risk of hospitalization for CHF (19 vs
  14) ?artifact, ?due to living longer?,
  ?detrimental

21
AICD guidelines

• Syncope in patients with advanced structural
  heart disease
• High risk of sudden cardiac death
• Inducible Vtach with structural heart disease
• Inducible Vtach with normal heart that is not
  amenable to ablation therapy

22
Subclavian Steal Syndrome

• Proximal subclavian artery stenosis
• Decreased blood flow to distal subclavian artery
  worsened with exertion of arm
• Blood from vertebral artery on opposite side goes
  to basilar artery and then down ipsilateral
  vertebral artery, away from brainstem, to serve
  as collateral for arm
• Usually asymptomatic
• Atherosclerosis
• Symptoms of vertebrobasilar insufficiency
  (dizziness, vertigo, diplopia, nystagmus)
• Rare to have permanent neurological deficits
• Diagnosis with dopplers, MRA
• Treatment surgical revascularization, stents

23
Cerebrovascular Disease

• Less common cause of true syncope
• Vertebrobasilar disease (presyncope)
• Drop Attacks

24
Vasovagal/Neurocardiogenic syncope

• Situational Syncope
• Micturition
• Defecation
• Cough
• Swallow
• Recurrent Neurocardiogenic Syncope
• Posprandial
• The FAINT

25
Vasovagal Syncope

• Presyncopal symptoms
• Setting (procedure, pain, anxiety)
• Prior history

26
Neurally Mediated Syncope

• Cardiac sensory receptors in LV stimulated by
  stretch
• Increased neural discharge to vasomotor center in
  medulla
• Increased parasympathetic tone and decreased
  sympathetic activity
• Sudden bradycardia and hypotension

27
Recurrent Neurocardiogenic Syncope

• Upright posture lead to pooling of blood in lower
  extremities
• Decreased venous return
• Normal response reflex tachycardia and forceful
  LV contraction and vasoconstriction
• Susceptible individuals activation of
  mechanoreceptors triggers reflex bradycardia and
  hypotension
• Response triggered by forceful LV contraction
  with prolonged standing or with increased
  catecholamines (anxiety, fear, panic, pain)

28
Treatment of Recurrent Neurocardiogenic Syncope

• Medications
• Paroxetine
• Only agent shown effective in RCT
• Midodrine
• Alpha adrenergic agonist
• Small studies
• Fludrocortisone
• No good study
• Beta blockers
• Often used, mixed evidence in studies

29
Pacemakers in the treatment of Recurrent
Neurocardiogenic Syncope

• 3 large RCTs of permanent pacing
• North American Vasovagal Pacemaker Study (VPS-1)
• Patients with over 6 episodes, positive tilt
  table test with significant bradycardia
• Significant decrease in recurrence with pacer (HR
  .087)
• Vasovagal Syncope International Study
• 5 recurrence with pacemaker vs 61 without (19
  patients)
• Syncope Diagnosis and Treatment Study
• Pacemaker vs atenolol
• 93 patients 4.3 recurrence vs 26

30
Pacemakers and neurocardiogenic syncope

• Problems with trials
• Small numbers of patients
• Not blinded
• Highly selected patients
• Patients had profound bradycardia on tilt table
  testing and multiple episodes

31
Pacers and neurocardiogenic syncope

• Bottom line
• May benefit patients with recurrent episodes of
  clear neurally mediated syncope, associated with
  significant bradycardic response, who have a
  decreased QOL otherwise (injuries, driving, etc)

32
Carotid Sinus Hypersensitivity

• ?Role of Carotid Sinus Massage
• Some recommend if no bruits, recent MI, cva or
  history of vtach
• ?monitor
• Positive response 3 sec pause
• In literature, but most cardiologists would not
  recommend
• High yield of carotid massage in elderly (up to
  40 over the age of 75 may have a positive
  response), but not specific in identifying this
  as the cause of syncope (PPV not known)
• History syncope/presyncope with turning neck,
  backing up in car, wearing tight collar

33
Evaluation of Syncope

• When a cause of syncope is identified, history
  and physical lead to etiology in up to 85 cases
• The only independent predictor of a cardiac cause
  of syncope is the presence of underlying heart
  disease (95 sens, only 45 spec)

34
Orthostasis

• May be confounder in older patients
• Up to 25 of older patients may have orthostasis
  when tested, the presence of orthostasis may be
  true, true and unrelated

35
The ECG

• Prolonged QT
• Bradycardia, AVN disease, MI, HOCM, Brugada
• Only 2-10 will have diagnostic abnormality
• Up to 50 of patients with syncope have abnormal
  EKG
• Greatest use in NPV (negative predictive value)
  of NORMAL ECG

36
The Holter Monitor

• 24-48 hours continuous ECG
• No added yield with 72 hours
• Low yield unless frequent symptoms
• Up to 70 of Holter studies negative for
  diagnosis
• One series only 5 of studies had arrhythmia
  that correlated with symptoms
• Probably good NPV if symptoms documented with
  benign rhythm

37
Event or Loop Monitors

• Higher yield than holter (up to 55 positive
  yield of symptom-arrhythmia correlation in some
  series)
• Problem with patient education and ability to
  activate monitor correctly (25 of patients have
  difficulty)
• May be especially problematic in the very elderly
  or those with dementia

38
Implantable Loop Recorder

• Prolonged monitoring for those with syncope of
  unclear etiology despite workup, especially for
  those in whom cardiac etiology is suspected
• Several small studies suggest that in very
  selected patients, may increase yield of
  diagnosis to almost 85

39
Other Cardiac Tests

• Echo
• Exercise or Functional Tests
• EP studies
• Most useful when history or physical suggests
  specific further testing to be done

40
Tilt Table Testing

• Passive or Isoproterenol
• Test patient held in upright position at 40-90
  degrees and observed for symptoms and hypotension
  or bradycardia
• Passive testing sensitivity of 70, specificity
  of 90-100
• Isoproterenol only 55 specificity
• Overall little to add to history and PE lack of
  sensitivity with passive testing and lack of
  specificity with induced testing limits
  usefulness of test

41
Lab tests

• The basics (anemia)
• ?BNP some studies report usefulness as a marker
  for cardiac cause of syncope sensitivity of 82
  and specificity of 92, Likelihood ratios of pos
  and neg tests probably not more useful than
  pretest probability of underlying heart disease
  based upon history and physical exam
• CK, MB and Troponins
• More useful if positive (greater PPV) than neg
• One series up to 10 nursing home patients
  presenting with syncope had positive enzymes

42
The Least Useful Tests

• CT head with negative neurological exam
• EEG with no neurological symptoms
• Carotid Artery Dopplers (useful for evaluation of
  CVA or TIA, not useful for evaluation of syncope
  without vertebrobasilar symptoms)

43
The Older Patient

• Positive tests that are more common in the
  elderly and not necessarily the cause of the
  syncope
• Orthostasis
• Positive carotid massage
• Positive tilt table testing
• Up to 54 of older patients with syncope may have
  positive test
• Positive test in 10 of asymptomatic elderly!

44
Algorithm for diagnosing syncope
Linzer, M. et. al. Ann Intern Med 199712776-86
45
Summary of Charges for Diagnostic Tests in
Syncope
Linzer, M. et. al. Ann Intern Med 199712776-86
46
Summary

• Syncope in the older patient usually
  multifactorial
• Tailor tests based upon history and physical exam
• Elderly more likely to have positive tests that
  may be confounders
• Elderly more likely to have underlying heart
  disease and higher pretest probability of a
  cardiac etiology
• Use algorithms in older, complicated patients
  with great caution!!!

47
Back to the Pretest

• 1. The ECG has the greatest value in its (NPV or
  PPV) in the diagnosis of a cardiac etiology for
  syncope
• 2. History 75 year old man reports presyncopal
  symptoms that occur while he is driving backwards
  out of his driveway in the morning. This
  suggests
• 3. History an 80 year old man reports an episode
  of syncope that occurred after doing arm
  exercises for a rotator cuff injury. This
  suggest
• 4. The only independent predictor of a cardiac
  etiology of syncope is a past history of
• 5. ____ is a neurodegenerative disease
  characterized by profound autonomic insufficiency
  and parkinsonian features on exam
• 6. An 82 year old man presents with postural
  hypotension, an idiopathic peripheral neuropathy,
  significant proteinuria and your attending orders
  a rectal biopsy to look for____
• 7. Name 3 causes of situational syncope
• 8. Older patients are more likely to have
  positive a. tilt table tests b. carotid sinus
  massage c. orthostatic hypotension d. all of the
  above

48
Answers to Pretest

• 1. NPV
• 2. Carotid Hypersensitivity
• 3. Subclavian steal syndrome
• 4. Cardiac history
• 5. Multiple Systems Atrophy (shy-drager)
• 6. amyloid
• 7. micturition, defecation, cough, swallow
• 8. all of the above
• 9. bonus brugada syndrome

49
Selected References

• Benditt DG, VanDjjk JG, Sutton R. Syncope Curr
  Prob Cardiol 2004 29(4) 152-229
• Epstein AE. An update on implantable
  cardioverter-defibrillator guidelines. Curr Opin
  Cardiology 2004 19(1) 23-25
• Littman L et al. Brugada syndrome and Brugada
  sign. Am Heart J 2003 145(5) 768-778
• Raj S, Sheldon RS. Role of pacemaker in treating
  neurocardiogenic syncope. Curr Opinion Cardiol
  2003 18 47-52
• Gregoratos G, Cheitlin MD, Conill A. ACC/AHA
  guidelines for implantation of cardiac pacemakers
  and antiarrthythmia devices executive summary
  a report of the American College of Cardiology/Am
  Heart Assoc Task Force on Practice Guidelines.
  Circulation. 1998 97 1325-1335
• Connolly SJ et al. The North American Vasovagal
  Pacemaker Study. J Am Coll Cardiol 1999 33
  16-20
• DiGirolamo et al. Effects of paroxetine on
  refractory vasovagal syncope. J Am Coll Cardiol
  1999 33 1227-30
• Sutton R et al. Dual chamber pacing in the
  treatment of neurally mediated tilt-positive
  cardioinhibitory syncope (VASIS). Circulation
  2000 102 294-299

50
Selected References

• Krahn Ad et al. Use of the implantable loop
  recorder in evaluation of patients with
  unexplained syncope
• Kapoor WN. Current evaluation and management of
  syncope. Circulation 2002 106 1606
• Alboni P et al. Diagnostic Value of history in
  patients with syncope. J Am Coll Cardiol 2001
  37 1921
• Kapoor et al. Evaluation and outcome of patients
  with syncope. Medicine 1990 69 160
• Linzer et al. Diagnosing syncope part I. Ann Int
  med 1997 126989
• Linzer et al. Diagnosing syncope part II. Ann
  Int Med 1997 127 76